Provider Demographics
NPI:1306240106
Name:GARDNER, TIFFANY MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:MARIE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1930 BISHOP LN FL 12
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218
Practice Address - Country:US
Practice Address - Phone:502-272-5220
Practice Address - Fax:502-272-5117
Is Sole Proprietor?:No
Enumeration Date:2014-10-22
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100346900Medicaid
IN201324590Medicaid
IN201324590Medicaid